About 20 years ago, some of us in the medical profession realized that the business of running a practice with a doctor, an office nurse, and a receptionist was not going to be sufficient in the future. The demands placed upon physicians would expand so much that they could no longer be met by solo practitioners. Assistance beyond the scope of the hospital-trained, office nurse would be required. In looking for an answer, we envisioned a mid-level provider who could take over some of the physician's work load and practice under the supervision and direction of the physician, but who did not require the same number of years of training as the physician

The PA Concept Emerges

In the mid-1950s, Dr. Thelma Engles and I organized a master's program in nursing, aimed at upgrading the clinical skills of nurses. Our graduates proved highly capable clinicians; unfortunately, our philosophy was ahead of its time. The master, program was never accredited and was finally cancelled by the League of Nurses. But we learned from the experience that a clinician did not need an MD degree to carry out many of the functions traditionally performed only by MDs.

Our next venture was in cardiology. During the early 1960s, the National Institutes of Health were willing to provide funds to train people in a variety of disciplines. We applied for and received grants to train, in an ap- prenticeship with a cardiologist, an "advanced cardio vascular nurse," to work in an acute-care cardiovascular laboratory.

The pilot program was so successful that we went to the nursing administration at Duke and offered to train a number of their nurses for expanded clinical roles. The nursing administrators turned us down for an understandable reason: they were already understaffed at the hospital, and were unwilling to give us any nurses to tupgrade.

By now, veterans were returning home from the Vietnam War. Those of us who had been fighting for advanced medical education for nurses elected to start a physician assistant program using ex-military corpsmen instead. From the start, we decided to provide our new pool of students a period of "schooling" rather than just an apprenticeship.

The First PA Program

We started the first PA Program with four students, all veterans-people whom we knew could take criticism. We recognized that if we wanted PAs to do what nurses were not doing-and what nobody else in the health profession was doing except MDs-we had to have people who could stand their ground.

Indeed, nurses and physicians at Duke Hospital were not overly enthusiastic about our idea. Their consensus was, "They won't be doctors, but you're trying to train them to be doctors-you're just going to produce a poor imitation." It was not easy to become a PA in those days.

From the start, we knew that besides the right students, we had to get the right person to administer the program. This person had to be a nurse, because we wanted PAs to know what nurses did. However, it was difficult to find a nurse who was willing to join our medical faculty and who was not afraid of being frowned upon by the nursing profession. The person we found at Duke to do this-and to whom I still owe a debt of gratitude-was Kay Andreoli.

Kay was self-assured professionally, certain enough of her own standing as a nurse to be convinced that the practitioner we were trying to create needed a much broader education in adult health care than could be obtained by just working in a hospital. She believed, as we did, that PAs should be definitively identified with, closely associated with, and mostly educated by physicians.

PAs vs Nurses: The Training

Today, this difference has narrowed, as nursing students have become more aggressive in their career demands. Some basic medical programs now admit nursing faculty, allowing them to spend one, two, or three years in medical school learning at the MD level. Meanwhile, PA programs have continued to use physicians to select, educate, and evaluate their students and to provide their graduates continued medical education. Although the gap in training nurses and PAs has closed over the years, PAs still maintain a unique advantage, given their dependent relationship with a supervising physician.

The Future of PAs

The future, then, depends upon how well PAs recognize their uniqueness within the health care delivery system, and to what extent they are willing to be liaisons between patients and the rest of the health care team. This is the distinguishing factor for PAs in today's marketplace. Today, many consumer groups are calling for patients to be better informed; yet, many patients still do not fully understand how their bodies work, the nature of their illnesses, nor the management thereof. Because of their specialized education, PAs can act as interpreters between physicians and patients. It is increasingly clear that this trend will open up many opportunities for PAs.

Where do these opportunities lie? One area is industrial medicine and toxicology. This discipline is just beginning to come to the forefront of people's attention. People have a heightened awareness of the impact that the environment has on their health-especially carcinogens introduced by industry. With additional technical skills, PAs could monitor the amounts of toxic substances in the work environment and make recommendations as to how best to reduce these hazards.

Another area where PAs have great career potent is in health care management. Prior to World War II, we generally assumed that a nurse who had been in a hospital for ten or 15 years could take over a hospital, or a doctor's office and run it. At some point, it became clear that this type of management was not going to work: nurses did not have the higher medical education needed to oversee the rapidly advancing technology being incorporated into the health care delivery system. True, in some areas, changes in nursing education has closed the gap; but Pas still-in terms of their medical education-maintain an advantage: they work with physicians, and are directly supervised by physicians. PAs are, therefore, more atuned to the needs of physicians and consequently are better qualified to serve administrators in hospitals or doctor's offices.

PA Education

PA programs should also add some training in law. As a doctor, I am not too fond of lawyers. Every time they get involved in the medical field, they try to make laws about biology, and because medicine is so complex they do it poorly. For example, they are now trying to determine whether someone is dead or not. I have been practicing medicine for a long time, and all the people I said were dead, by God, they were dead! Nevertheless if we had better-informed lawyers in the health care field we might be better off. Mix the skills of the PA and the skills of the lawyer, put in a little general education, and in four or five years you have a unique and very useful person bridging the gap between medicine and law.

Conclusion

As time goes on, more and more places are going to seek people with PA backgrounds. The marketpIace looks good for physician assistants; a bright future out there. All that remains is for each PA to seize the opportunity.

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